AbstractFemale genital fistula, a debilitating birth injury frequently caused by prolonged obstructed labor or surgery in lower-resource settings, leads to stigma and poor health, social, and economic outcomes.Fistula-related stigma evidence is lacking, including the nature, dimensions, sources, and influences on health and wellbeing. This systematic scoping review aimed to examine fistula-related stigma experiences; assess stigma and discrimination consequences; and 3) compare how stigma, its severity, and related stigma coping and resistance differ across contexts. We searched 10 scientific databases for original research on fistula-related stigma through June 8, 2021. Findings were thematically analyzed andsummarized in table and narrative format. We calculated pooled prevalence for divorce/separation, anxiety and depression. 199 unique articles were identified across 41 countries, predominantly from sub-Saharan Africa. Findings highlight multiple manifestations of fistula stigma including enacted, internalized, anticipated, caregiver, and structural stigma. Fistula stigma intersected with infertility, gender, disabilityand poverty stigma. Stigma consequences included mental health and psychological distress, lost employment/income, and limited social engagement. Pooled prevalence of divorce/separation was 35%(95% CI 30%-41%), depression 65% (95% CI 56%-74%), and anxiety 52% (27-75%). Common coping strategies included self-isolation or social withdrawal and keeping oneself clean; stigma resistance was rarely reported. Social support was protective of stigma. Few stigma interventions were identified; none evaluated implementation context or strategies to inform adoption and sustainability. Clinical interventions (e.g. counseling) addressed psychosocial and mental health consequences, and community-level interventions addressed community stigma. Assets-based or strengths-based framing was uncommon. Knowledge gaps impede theory and evidence-based optimization of clinical and social services for fistula-related stigma prevention and mitigation, impacting quality of life.

Clinical Impact Statement: This study found that individuals with female genital fistula reported multiple stigma types. Fistula stigma impacts mental health, quality of life, and ability to work, and engage withothers. Social support reduced fistula stigma impact. Few interventions to reduce fistula stigma were found in the literature. Interventions to reduce fistula stigma in clinical care or social services couldsubstantially improve the quality of life of women living with fistula.